Periocular Acupuncture Safety: Concerns Centered on Proper Practice, Not Inherent Acupuncture Risks

Dear Editor,

We recently read an article published in your esteemed journal regarding the safety of periocular acupuncture with great interest but also with concerns [1]. Acupuncture is known to be used in at least 100 countries worldwide [2], and this number seems to continue increasing. The fact is, acupuncture is a safe intervention when performed by well-educated and trained practitioners in a suitable environment, adhering to established standards as in Western medicine. It has already been supported by various large-scale prospective and retrospective studies [3]. The same applies to acupuncture practice in the field of ophthalmology.

As practitioners who have personally performed acupuncture in clinical settings for over a decade, we have been involved in numerous clinical studies aimed at establishing evidence for acupuncture, including clinical trials on acupuncture dry eye syndrome [4]. To briefly summarize one study, patients with dry eye syndrome received treatment at commonly used acupoints including periocular lesion, such as GB14, BL2, TE23, and ST1, three times a week for 4 consecutive weeks. The only acupuncture-related adverse event in this study was local bleeding at the treatment site, occurring in 3 out of 75 patients. Importantly, only a few of these incidents were associated with periocular acupoints [4]. This result highlights that the application of acupuncture in the periocular region is not always directly linked to serious adverse events.

We understand the concerns of the authors as ophthalmologists regarding the potential adverse events of periocular acupuncture [1]. However, it is crucial to note that their conclusions might be somewhat exaggerated for several reasons.

First, the authors’ research methodology for assessing the risk of periocular acupuncture can exaggerate the actual level of risk. In general, case reports serve the purpose of documenting the effectiveness of novel, relatively unknown interventions or the occurrence of uncommon adverse events in the medical field. It is natural for common occurrences in clinical practice to not be well covered in case reports. Although case reports can be useful in recognizing and organizing infrequent but serious adverse events, they also have limitations in establishing a clear causal relationship between intervention and adverse events, and there is a risk of recall and publication bias [5]. In this sense, the methodology of this study is insufficient to draw generalized conclusions regarding safety, so it is worth reconsidering whether concluding that “acupuncture therapy around the eye is a risky procedure” based on a review of case reports is entirely reasonable [1].

Second, safe procedures reduce the risk of adverse events. As the authors commented, the primary issue is acupuncture being performed by individuals without proper qualifications or training, in inappropriate clinical settings, and without appropriate infection-prevention measures. In the authors’ case review, at least half of the cases involved unclear practitioners or unqualified individuals, leading to adverse events.

Finally, considering common acupuncture practices, periocular acupuncture can also be considered very safe. In our previous acupuncture study, all acupuncture points were located according to the WHO Standard Acupuncture Point Locations in the Western Pacific Region [6], and when needling, the direction of the acupuncture was adjusted to avoid direct penetration into the patient’s orbit, and the depth of needle insertion was very shallow, around 3 to 6 mm. Sterilized, disposable stainless steel needles with a size of 0.20 × 30 mm were used, and clean needle techniques were adhered to during the procedure. Of course, it goes without saying that qualified Korean Medicine doctors with appropriate education and clinical experience participated in our study. We did not experience any severe adverse events as we described before [4].

In summary, while recognizing the potential risks of periocular acupuncture is essential, it is also crucial to consider the context in which the procedure is performed, the qualifications of the practitioner, and the limitations of case report-based conclusions. It is reasonable to assume that periocular acupuncture is performed within an acceptable level of safety for common practices. In addition to this, it should be recommended that studies dealing with acupuncture safety are necessary to clearly distinguish between unlicensed acupuncture practitioners and licensed Korean Medicine doctors, at least in South Korea in the future.